Study Doubts Melanoma is Epidemic

They discovered, however, that there was no change in the death rate from the lethal form of skin cancer. They also discovered that the incidence of advanced melanoma disease also did not change.

Dr. Welch and his colleagues insist that if there was really an epidemic of melanoma - if for example, something in the environment was causing people to get the skin cancer, scientists should see increases in cancers at all stages. According to the Times, this is what happened with lung cancer caused by smoking, and with other cancers caused by toxic substances.

The fact, however, that the increase was seen only in very early stage disease was a tip-off that the epidemic might be less than it appears to be, Dr. Welch explained.

This, he says, leads to a difficult question. The point of screening for melanoma is to reduce the death toll from the cancer, yet if screening has not altered the number of patients with advanced disease or lowered the death rate, what is its benefit?

He and his colleagues added, however, that people who notice suspicious moles or spots should not hesitate to see a doctor. But skin cancer screening, they said, is directed at healthy people who have no reason to suspect that anything is wrong.

While admitting that more and more people are having skin biopsies, Dr. Darrell Rigel, a dermatologist in New York, said he questioned Dr. Welch's conclusion that the biopsies were leading to excessive diagnoses of melanoma. "I would say the inverse is more likely," Dr. Rigel said. "There are more melanomas and therefore more biopsies."

At the American Cancer Society, Dr. Len Lichtenfeld, an oncologist, told the Times his group reviewed the same data as Dr. Welch and came to a different conclusion.

Screening, he said, appears to be saving lives. He cited a trend in the data indicating that the death rate from the disease rose slightly year by year until about a decade ago. That, he told the Times is consistent with an increase in serious cases of melanoma.

Now, he said, "there has been a suggestion in the data that the death rates in the Medicare age group are going down," an effect that would be expected if screening was working, adding that "We agree that some of the melanomas are biologically indolent, but we also feel that when we look at the trend in the data and the suggestion of decreased mortality that there has been a benefit from increased surveillance for the disease."

The cancer society, countered Dr. Welch was "taking tiny, tiny differences" in death rates from year to year and "putting a huge microscope on it." In fact, he said, the death rate has been basically flat since 1986, although it bounces around slightly from year to year as a result of statistical fluctuations.

"We don't disagree about the data," Dr. Welch added. "We disagree about the interpretation. We are not arguing that there is zero change in disease burden. We are arguing that most of the newly diagnosed cases are the result of increased screening."

The Times recalled that two dermatologists, Dr. Robert Swerlick and Dr. Suephy Chen of Emory University and the Atlanta Veterans Affairs Medical Center, wrote in a 1997 article that while some people might be saved by screening, there also are risks from a melanoma diagnosis.

"After a patient has received the diagnosis of melanoma, obtaining insurance can be extremely difficult," they wrote.

"The diagnosis of melanoma also results in heightened scrutiny of all first-degree relatives and family members of the patient, and if increased surveillance leads to increased diagnosis, this process may also put them at risk for the diagnosis of melanoma."

For his part, Dr. Welch says that early detection "is a double-edged sword and people need to remember that."

A few people might be saved because a cancer is found early, he said, but many, many more will be thrown into the medical mill when there is nothing wrong with them.

"People should realize that is the price we pay for screening," Dr. Welch said, and although screening is widely promoted, "we ought to know whether it helps."

They discovered, however, that there was no change in the death rate from the lethal form of skin cancer. They also discovered that the incidence of advanced melanoma disease also did not change.
Dr. Welch and his colleagues insist that if there was really an epidemic...